Ana's Residence Care Facility

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 09:44 AM. LPA met with facility staff who contacted the facility Administrator Anna Atayan. The Administrator arrived to the facility at 10:09 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:10 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed two (2) secured cabinets to contain resident medication. Additionally, LPA observed the kitchen to contain sufficient emergency food supplies, the facility’s washer and dryer as well as the facility’s first aid kit. LPA observed a camera in the kitchen area. LPA confirmed with the facility Administrator that audio is not recorded. GARAGE: LPA observed the garage to be locked inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, emergency water supplies, and an extra refrigerator. Additionally, LPA observed the garage to contain a couch and a bed for staff use. Continued on LIC 809C. COMMON AREAS: This includes the living room, hallway, and dining room. LPA observed the living room to be clean and in good repair. The living room contained adequate seating and activities for resident use. LPA observed a fire extinguisher mounted in the living room to be fully charged and purchased on 02/24/2025. LPA observed a hallway closet to contain extra linens. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contained a dining table with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms, as well as the facility fire door, were tested at 01:16 PM and were functional at the time of the visit. BEDROOMS: There are five (5) bedrooms in the facility; one (1) is a dual occupancy room and four (4) are single occupancy rooms. LPA and facility Administrator toured all five (5) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as private resident bathrooms, and one (1) bathroom is designated as a shared resident bathroom. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near resident toilets, all were properly secured. LPA observed the shared resident bathroom to contain appropriately secured cabinets which contained personal grooming supplies for resident use. The water temperature was measured between 117.3 and 118.0 degrees Fahrenheit, which is in compliance with regulation. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the outdoor deck to be connected to the facility hallway and bedroom#4 and bedroom #5. All railings on the deck were properly secured. LPA observed cameras in the outdoor spaces of the facility. Continued on LIC 809C. RECORD REVIEW: Record review began at 10:37 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained all required documents and trainings. Six (6) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review. MEDICATION REVIEW: Medication review began at 12:50 PM. Medications for three (3) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 09/17/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed two (2) residents and two (2) staff members. Both residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. One (1) staff interview was conducted with the assistance of the facility Administrator acting as a translator. Both staff members interviewed understood their roles and responsibilities, the resident’s rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 2, 2025

Allegation investigated: Staff are not adequately trained.

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. LPA arrived at 1:37PM and met with the Licensee Anna Atayan and explained the reason for the visit. On 05/05/2024, LPA Christine Yee conducted an initial unannounced complaint investigation visit. Beginning at 10:40AM, LPA Yee reviewed and obtained copies of five (5) residents' Identification and Emergency Information, Physician Reports, Appraisal/Needs and Services, and copies of the Staff training log dated from 2018 to 2023. Between 11:57AM and 12:32PM, LPA interviewed two (2) residents and the Licensee. Report Continued on LIC 9099-C Substantiated On 06/13/2025, LPA Huynh conducted an unannounced subsequent investigation visit. The LPA toured the facility at 11:26AM, reviewed staff and resident files beginning at 11:48AM, and obtained pertinent documents. Throughout the duration of the visit, LPA interviewed two (2) residents and two (2) staff along with the Licensee. During today’s visit, the LPA and Licensee toured the physical plant areas at 1:40PM to ensure there are no health and safety hazards. Based on observations, interviews, and documentation gathered and reviewed, the following was then determined: Allegation: “Staff are unable to assist residents in care due to language barrier” It was alleged that residents and staff cannot communicate due to a language barrier and therefore staff is unable to assist residents with their needs. Interviews with four (4) Residents revealed that staff can understand and assist them with their requests. Resident #1 (R1) and Resident #2 (R2) stated that when staff do not understand their needs, the staff and residents would utilize their phone to assist in translating. R2 stated they only use a translator, or text the Licensee, when they have more complex requests such as meal preparations. Resident #3 (R3) stated staff can be slow to respond but can understand what they need assistance with. R3 also stated that if staff does not understand them, they would point/gesture to what they’re requesting. R2 would also assist R3 with communicating and expressed that Staff #1 (S1) understands R3’s needs very well. Interview with S1 and Staff #2 (S2) revealed that they understand English but have trouble speaking it. The interview was conducted with the Licensee who assisted with translating open-ended questions. Interview with the Licensee revealed that the facility’s staff know little English, however they are learning and can understand and are able to assist residents. The Licensee stated that staff and residents text them, along with the on-call Administrator, every minute of the day regarding residents’ needs. In emergencies, staff will notify the Licensee and Administrator, who live close by and can respond right away. Emergency services are called by the Licensee and the Administrator. Report Continued on LIC 9099-C Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency for the above allegation was cited. Exit interview conducted. A copy of today’s report was reviewed and provided. On 06/13/2025, LPA Huynh conducted an unannounced subsequent investigation visit. The LPA toured the facility at 11:26AM, reviewed staff and resident files beginning at 11:48AM, and obtained pertinent documents. Throughout the duration of the visit, LPA interviewed two (2) residents and two (2) staff along with the Licensee. During today’s visit, the LPA and Licensee toured the physical plant areas at 1:40PM to ensure there are no health and safety hazards. Based on observations, interviews, and documentation gathered and reviewed, the following was then determined: Allegation: “Staff are not adequately trained” It was alleged that staff were not sufficiently trained and do not know how to care and assist residents. Upon employment, staff are required to complete 40 hours of initial training before working directly with residents per regulation. The 40 hours of initial training can be transferred, however Dementia Care, Building and Fire Safety, Emergency Response, and Medication training cannot be transferred. Each year thereafter, staff are required to complete 20 hours of annual training with an additional 8 hours of Medication training. The annual 20 hours of training include: 8 hours of Dementia Care, 4 hours of Postural Support and Hospice Care as well as Restricted Health Conditions, and 8 hours of any General topics from the initial training. Record review and interview revealed that Staff #2 (S2) was hired on 05/15/2025 and their initial 40 hours of training were transferred from a previous facility, however the non-transferrable training hours were not completed after employment. Staff #1 (S1), Staff #3 (S3), and Staff #4 (S4) met their initial 40 hours of training requirement. From 2023-2024, S1 and S3 received 2 hours of Medication training, therefore did not meet their annual Medication training requirement. From 2024-2025, S1 did not receive their annual Medication, Postural Support, Hospice Care, Restricted Health Conditions, and General training requirements. Additionally, S3 did not receive their annual Medication, Postural Support, Hospice Care, and Restricted Health Conditions training requirement. S4 received their annual 20 hours of training from 2023-2024. Report Continued on LIC 9099-C During record review, the LPA observed S1’s 1st aid/CPR certification expired on 02/05/2025 and the Licensee provided a renewed certification effective 06/13/2025. S1 was directly assisting residents for four (4) months without an updated certification, therefore the Licensee and S1 did not maintain their training requirement. Interviews with the staff and the Licensee revealed that all staff assist residents in administering medications, with the exception of S4 who does not directly assist residents. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted. A copy of the appeal rights and today’s report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 29-AS-20240501152453

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jun 27, 2025

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on observation, interview, and record review, the Licensee did not comply with the section cited above, as 1 staff did not complete their initial 40 hours of training and 3 staff did not meet the annual training requirements, which poses/posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: The Licensee will have S2 complete their non-transferrable initial training and send proof to CCLD. The Licensee will review the training requirement regulations and send CCLD a written plan to implement the training requirements and specify the required hours and topics.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh conducted a conducted an unannounced visit at the facility in conjunction to an investigation of complaint control 29-AS-20240501152453. LPA arrived at 10:54AM and met with Staff Armine Melkonyan (S1), who spoke little to no English. LPA spoke with Licensee Anna Atayan at 10:57AM via telephone call and explained the reason for the visit. The Licensee arrived at 11:25AM. Entrance interview conducted During today’s visit, LPA Huynh and the Licensee conducted a tour of the physical plant areas at 11:26AM to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA observed Resident #1 (R1) was bedridden and residing in Bedroom #1. The facility is cleared for bedridden residents to reside in either Bedrooms #4 or #5, with only one (1) bedridden resident at a time. At 12:27PM, LPA reviewed resident files and obtained copies of two (2) residents’ physician reports and appraisal. Pursuant to Title 22 of the CA Code of Regulations and/or Health and Safety Code, the following deficiency was cited. (Refer to LIC 809-D). An immediate civil penalty of $500 for a violation of the facility’s fire clearance was issued (Refer to LIC 412M). The Licensee understands that continued violation of the facility’s fire clearance may result in additional civil penalties. Exit interview conducted. A copy of the appeal rights and report was reviewed and issued.the state’s words, verbatim · CDSS document, Jun 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Jun 16, 2025

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. ... This requirement is not met as evidenced by: Based on observation, the Licensee did not comply with the section cited above as 1 bedridden resident was residing in Bedroom #1 not approved for bedridden residents, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: The Licensee agreed to relocate the bedridden resident into one of the two approved bedridden Bedrooms (#4 or #5) and send proof to CCLD by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:59 AM. LPA met with facility staff who contacted the facility administrator Anna Atayan. The administrator arrived to the facility at 10:22 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:23 AM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed two (2) secured cabinets to contain resident medications and a first aid kit. The facility’s washer and dryer are located in the kitchen and a door to the garage was observed to be locked and inaccessible to clients in care. LPA observed a camera covering the kitchen area and entrance to the garage. LPA confirmed with the facility administrator that audio is not recorded. GARAGE: LPA observed the garage to be inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, emergency food and water supplies, an extra refrigerator, and a secured cabinet containing facility files. LPA observed the garage to contain a couch and a bed, the facility administrator confirmed that the garage doubles as a staff room. Continued on LIC 809C. OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed storage for wheelchairs and extra care supplies. An outdoor deck was observed to be connected to the facility hallway and bedroom numbers four (4) and five (5). All railings on the deck were properly secured. LPA observed cameras in the outdoor spaces of the facility. BEDROOMS: There are five (5) bedrooms in the facility; one (1) is a dual occupancy room and four (4) are single occupancy rooms. The garage is designated as a staff room. LPA and facility administrator toured all five (5) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. One (1) resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and all were functional at the time of the visit. BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as private resident bathrooms, and one (1) bathroom is designated as a shared resident bathroom. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 106.5 and 117.1 degrees Fahrenheit, which is in compliance with regulation. LPA observed the shared resident bathroom to contain appropriately secured cabinets containing personal grooming supplies for resident use. COMMON AREAS: This includes the living room, hallway, and dining room. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains a dining table with adequate seating for resident use. The living room was observed to be clean and in good repair. LPA observed a fire extinguisher mounted in the living room to be fully charged and purchased on 01/11/2024. The living room contained adequate seating and activities for resident use. LPA observed a hallway closet to contain extra linens. The facility’s combination fire and carbon monoxide alarms, as well as the facility fire door, were tested at 12:44 PM and were functional at the time of the visit. Continued on LIC 809C. RECORD REVIEW: Record review began at 10:50 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review. MEDICATION REVIEW: Medication review began at 12:04 PM. Medications for five (5) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 09/19/2024. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. INTERVIEWS: LPA interviewed two (2) residents and two (2) staff members. The residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. Both staff interviews were conducted with the assistance of the facility administrator acting as a translator. Both staff interviewed understood their roles and responsibilities,the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: Staff caused an injury to a resident while in care.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Anna and explained the reason for the visit. On 01/18/2024, the Department received a complaint alleging Neglect/Lack of Care and Supervision regarding Resident #1 (R1). The complaint alleged Staff #1 (S1) failed to provide supervision to R1 resulting in R1 sustaining a fracture. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Heidy Bendana. On 01/19/2024, from 10:30am to 12:05pm, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial visit to investigate the allegation listed above. LPA Urena arrived at 10:30am and was greeted by staff who contacted the licensee/administrator Anna Atayan. The LPA explained the reason for the visit and the licensee/administrator arrived shortly thereafter. At 11:00am the LPA requested records pertaining to the investigation. At 11:15am the LPA interviewed the licensee/administrator. The LPA determined further investigation was needed before delivering the findings. Substantiated Pg. 2 On 02/08/2024, from approximately 9:43am to 10:53am, Investigator Bendana conducted interviews with residents, R1, licensee/administrator, and staff; on 03/11/2024, at approximately 2:43pm, with S1; on 04/15/2024, at approximately 9:20am, with R1’s resident representative; and on 04/17/2024, at approximately 2:54pm, with the reporting party. In addition, Investigator Bendana reviewed Glendale Adventist Medical Center medical records, Palermo Hospice medical records, and facility file documents related to R1. According to the facility file documents reviewed, R1’s physician’s report, signed and dated by the physician on 07/10/2023, listed R1’s primary diagnosis as heart disease, dementia, and muscle weakness. It is noted R1 has mild cognitive impairment with an unsteady gait. R1 is confused and disoriented at times but can communicate and follow instructions. R1 needs assistance with activities of daily living (ADLs), is non-ambulatory, not able to transfer to and from bed, and uses a walker. Under the comments, it is noted that R1 is a fall risk and needs maximum assistance. R1’s appraisal needs and services plan, dated 08/01/2021, also indicated R1 needed assistance with ADLs, and needed assistance moving around the facility due to poor functioning body and needs full assistance in using functioning skills. The preplacement appraisal information for R1, dated 07/25/2021, listed R1 cannot ambulate independently due to muscle weakness. The investigation revealed that R1 had been a resident at the facility for approximately three years and had been frequently getting UTIs (urinary tract infections). On 01/06/2024, the licensee/administrator called R1’s resident representative to inform that R1 was “confused” and suggested “maybe” R1 needed medical care. R1 complained about pain in the “abdominal area and back” which R1 complained about when R1 had UTIs. R1’s resident representative then came to the facility to find R1 in excruciating pain and transported R1 to the Glendale Adventist Medical Center. Pg. 3 A review of the medical records indicated R1 was admitted to Glendale Adventist Medica Center on 01/06/2024 with the chief complaint of back/abdominal pain, nausea, vomiting and confusion. History of UTIs, hypertension, dyslipidemia presented to the emergency room with altered mental status. Patient (R1) was brought into the emergency department for generalized weakness, more altered than usual, with chills and weakness, abdominal pain. A CT scan without contrast of the abdomen/pelvis was conducted which revealed an acute T11 compression fracture. On 01/10/2024, R1 was discharged with a diagnosis of Covid-19 virus infection; altered mental status, and UTI. A review of the Palermo Hospice medical records indicated R1 was placed on hospice care at the facility on 01/11/2024. The records listed the chief complaint as chronic ischemic heart disease. R1 was also listed as non-ambulatory, bed bound, or wheelchair needed maximum assist, and a high fall risk. The information obtained from interviews revealed that the licensee stated R1 did not have any falls but that maybe R1 suffered the fracture on the way to the hospital, at the hospital, or maybe at the facility. The facility staff denied that R1 had any falls. S1 claimed R1 did not fall. S1 explained when assisting R1, R1 stated they were in pain, R1’s “back” was “hurting” and did not want to “get up.” S1 said they did not know if R1 was given pain medicine; it was “not” S1’s “responsibility” to “give” R1 medicine. S1 claimed R1 did not have a fall under S1’s care and could not explain why R1 was in pain. S1 remembered R1 complained of pain “all day.” S1 stated S1 informed the licensee/administrator who then notified R1’s resident representative. The investigation further revealed that R1 reported to R1’s resident representative, that S1 dropped R1 while assisting R1 in the bathroom. R1 reported that “S1 dropped them, they fell on their butt, and it really, really hurts”. Furthermore, the CT scan at the hospital revealed R1 sustained a T11 compression fracture. Pg. 4 On the allegation “Staff caused an injury to a resident while in care” - the Department’s investigation provided sufficient evidence to substantiate neglect/lack of supervision. Medical records showed R1 sustained a T11 compression fracture. R1 reported S1 “dropped” R1. R1 stated they complained of pain. R1’s resident representative stated R1 was in “excruciating pain” and would scream when R1 was moved or tried to move. The licensee/administrator stated R1 may have fallen at the facility. S1 failed to adequately assist R1 resulting in R1 sustaining a T11 compression fracture, therefore, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issuedthe state’s words, verbatim · CDSS document, May 29, 2024 · control 29-AS-20240118120829

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jun 14, 2024

1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. S1 failed to adequately assist R1 resulting in R1 sustaining a T11 compression fracture while in care, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: Licensee will submit a plan how you will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 06/14/2024.

Type of visit: Case Management - Deficiencies

During the complaint investigation of complaint #29-AS-20240118120829, the following deficiencies were observed: Staff failed to seek medical attention for Resident #1 (R1) in a timely manner. The licensee/administrator and staff reported R1 complained of abdominal and back pain. The licensee/administrator called R1’s resident representative and told them to call an ambulance because R1 was not well. R1’s resident representative came to the facility and observed R1 was in “excruciating pain” and would scream when R1 was moved or tried to move. R1’s resident representative then took R1 to the hospital. Medical records showed R1 sustained a T11 compression fracture. R1 reported Staff #1 (S1) “dropped” R1. The licensee/administrator and staff failed to call 911 or R1’s doctor to seek medical attention for R1. Staff #1 (S1) advised they were a caregiver at the facility for approximately one week. The licensee/administrator reported that S1 worked at the facility from 01/01/2024 to 01/13/2024. S1 was covering for a caregiver who was on vacation. S1 was fingerprint cleared but was not associated to work at the facility. An Immediate $500 Civil Penalty is assessed today. A review of the Palermo hospice medical records indicated R1 was placed on hospice care at the facility on 01/11/2024. There is no evidence or confirmation that the hospice notification was submitted to Community Care Licensing (CCL). Citations issued, Immediate $500 Civil Penalty issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, May 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 14, 2024

87465(a)(1) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and medical records, the licensee did not comply with the section cited above. The licensee/administrator or staff did not seek medical attention when R1 complained of abdominal and back pain, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: The licensee will submit a plan describing how you will ensure residents will receive timely medical care. Submit proof to CCL by 06/14/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355 · Plan of correction due date: Jun 14, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). (f) Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above. S1 was not associated to the facility yet worked at the facility from 01/01/2024 to 01/13/2024, which posed an immediate health and safety risk to residents in care. Immediate $500 civil penalty assessed.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: The licensee will submit a plan describing how you will ensure staff are fingerprint cleared and associated to the facility prior to working. Submit proof to CCL by 06/14/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(d)(2) · Plan of correction due date: Jun 7, 2024

Hospice Care Waiver (d)(2)If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include…the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility…This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. There is no evidence or confirmation that the licensee submitted a notification for R1’s 01/11/2024 initiation of hospice care services, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: The licensee will submit a plan describing how you will ensure notification of the initiation of hospice care services is met within the required time frame. Submit proof to CCL by 06/07/2024.